| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Repeat 12/14/16: This agency has neglected to care for Individual #1's health concerns as noted in the information below. The agency did not implement health services as specified by healthcare professionals or provide staff with necessary training in order to care for Individual #1. According to Individual #1's blood sugar protocol in his/her record from the PCP if 'blood sugars before meals are running between 130-200 for 3-5 days in one week staff are to discuss the treatment plan with provider'. On 11/19/17, 11/21/17, 11/22/17 1/23/17, 11/24/17, 11/25/17, 11/26/17 and 11/27/17 all of Individual #1's AM blood sugar levels were above 130. Individual #1 is to have his/her blood sugar levels checked twice daily at 7:30 am before breakfast and before bedtime. On 1/03/18 Individual #1's morning and evening blood sugar levels were not checked and on 1/04/18 the morning blood sugar levels were not checked due to not having supplies available at the home to complete the blood sugar level checks at these times. On 2/15/18 Individual #1's morning blood sugar levels were not checked and staff indicated that the blood sugar levels couldn't be checked due to the fact staff did not know how to use the lacet machine. Individual #1's physical completed on 1/17/18 indicated that he/she is to have a colonoscopy completed every two years. Individual #1's last colonoscopy was completed in July of 2014. A colonoscopy was due in July of 2016.
On Individual #1's 1/17/18 physical it indicated he/she needed to shower daily. Attached to the physical was a note from the physician stating a concern over Individual #1's appearance and hygiene at the time of the physical. The note stated 'I was very concerned about his/her appearance and the case worker could not verify that he/she indeed did shower. Nor could I establish when he/she changed his/her socks last, since they were soiled and two toes going thru-hence comment re; shower and clothing change'. Individual #1's 2017 physical indicated that he/she needs to shower at least every other day. The residential home was not documenting his/her showering for the past two years. The concerned note written by the doctor on 1/22/18 was not printed and put in Individual #1's record until 2/20/18, the first day of licensing. According to Individual #1's 2017 and 2018 physical he/she is prescribed to wear compression socks daily due to varicose veins. The residential provider never purchased compression socks for Individual #1. A vein therapy appointment was made for 6/30/17 however was canceled. The note in the record from staff indicated that appointment was cancelled due to Individual #1 never receiving his/her compression socks. Individual #1 still did not have compression socks at the time of the home inspection on 2/22/18. On 7/12/16 there was a letter in Individual #1's record from the advocacy alliance, south central Health Care Quality Unit (HCQU) nurse that recommended a dementia screening be completed due to Individual #1's confusion and memory loss. Individual #1 still had not received a dementia screening at the time of this inspection. There is no documentation from the residential provider of attempts to discuss a dementia screening with Individual #1's doctors. Individual #1 is recommended to have yearly vision exams. Individual #1 had a vision exam on 11/14/16 and not again until 12/8/17. Individual #1's 3/24/17 hearing evaluation indicated mild to moderate high frequency neurosensory hearing loss and that he/she needs hearing aids. Individual #1's April 2017 audiologist appointment indicated that he/she needs hearing aids. At the time of licensing on 2/20/18 there was no documentation to indicate the agency attempted to obtain hearing aids for Individual #1. Individual #1 is diagnosed with diabetes and sees a podiatrist. Individual #1 had a podiatry appointment on 5/12/17 and not again until 10/6/17. An appointment was scheduled for 7/17/17 but did not occur. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | All residential management were re-trained on documentation training on March 26, 2018. All appointments that were outstanding were scheduled. The dementia screening is scheduled April 19, 2018, hearing appointment is April 25, 2018, the neurosurgeon appointment to discuss fluid on the brain and CT referral is April 10, 2018. Staff is getting colonoscopy referral again as previous prep was not completed. BSL protocols are being updated by the PCP as his A1C is at the normal to slightly elevated range. See attachments for shower and refusal for medical treatment plans. This home only had 1 full time staff during the past year and had a lot of inconsistent staffing in the home. Shadowfax has hired all the full time postions in the home and this home is fully staffed now. Shadowfax is also hiring additional Program Specialists for oversight and monitoring so each PS has more time to spend with each person. The Associate Director position that was vacant has been filled and the person is making weekly visits to ensure the health needs of individual # 1 are being met. Going forward to prevent future occurrences, the Associate Director will make weekly visits and check all appointment information, all health concerns, and necessary health care is completed. The Associate Director and Program Specialist will ensure training of staff specific to the individuals' needs. The Director will monitor on house visits as well. Additionally, staff that do not follow through in a timely manner will receive corrective action up to and including termination. |
04/25/2018
| Implemented |
| 6400.16 | At Individual #1's dental appointment on 1/18/17 it was indicated that he/she was to get a water pick and wear a night guard. There is no indication in Individual #1's record that he/she is using a water pick or wearing a night guard. It was not until the dental appointment on 3/1/17 that it was indicated that Individual #1 had a night guard and it was adjusted. Individual #1's dental appointment on 3/1/17 indicated that Individual #1 is to bring his/her night guard to all other appointments. There was no documentation that Individual #1's night guard was brought to any other dental appointments. On 7/6/17 Individual #1 had stroke like symptoms and he/she refused to go to the emergency room. On 7/12/17 Individual #1 followed up with his/her primary care physician from ER visit and refused to have a cat scan completed. Between 7/12/17 and 7/19/17 there was a note that the doctor's office was called due to Individual #1 feeling sick, taking his meds and then vomiting his meds and retaking them. There is no indication that Individual #1's doctor was notified of all of his/her stroke like symptoms. At Individual #1's medication review on 6/6/17 it was recommended to follow up with a neurologist. There was no documentation in Individual #1's record that follow up with a neurologist occurred or attempts to schedule an appointment with a neurologist were made. At Individual #1's medication review appointment on 11/28/17 it was indicated that he/she was to have blood work completed in 1-2 weeks due to stopping benztropine and starting amantadine. Blood work was not completed for Individual #1 until 12/22/17. Individual #1's psychiatrist discontinued his/her Amantadine medication on 2/13/18. However the home continued to administer this medication to Individual #1 until 2/22/18 when licenser brought to the agency's attention that the doctor had discontinued the medication. According to Individual #1's medication administration records (MAR) for February of 2018, Individual #1's Quetiapine 8 am dose of medication was not administered on 2/3/18 due to the medication not being refilled in time. On 2/10/18 Individual #1's 8 am medications of Vitamin D and Finasteride were not administered due to the medications not being at the home. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | All issues addressed in this citation have been addressed in each individual citation. Refusal for treatment plans were developed and instituted. A medication error training has been scheduled for April 10, 2018. Shadowfax has hired all the full time positions at this home to provide consistency, including the Associate Director who is responsible for overseeing the house. Shadowfax is hiring more Program Specialists to spend more time monitoring and overseeing the care of each individual on their caseload. All residential management were re-trained on documentation on March 26, 2018. The Associate Director position that was vacant has been filled and that person is making weekly visits to ensure the health needs of individual # 1 and housemates are being met. Going forward to prevent future occurrences, the Associate Director will make weekly visits and check all appointment information, all health concerns, and necessary health care is completed. The Associate Director and Program Specialist will ensure training of staff specific to the individuals' needs. The Director will monitor on house visits as well. Additionally, staff that do not follow through in a timely manner will receive corrective action up to and including termination. |
04/10/2018
| Implemented |
| 6400.18(c) | Individual #1's wallet was discovered missing on 8/28/17. An incident report was not entered until 8/31/17. | The home shall orally notify the county intellectual disability program of the county in which the home is located, the funding agency and the appropriate regional office of intellectual disability, within 24 hours after abuse or suspected abuse of an individual or an incident requiring the services of a fire department or law enforcement agency occurs.
| The DSP notified their supervisor instead of the IM Point person resulting in a late report. The IM point person re-trained staff on IM procedures on 9-1-17. The IM person evaluates the effectiveness of re-training staff to ensure DSP's are following the established protocol once re-trained. Associate Directors were re-trained on 3-26-18 that when they get a call regarding an IM issue, that they must ask the staff to contact the point person immediately. The Associate Directors will also contact the point person themselves as the IM point person needs to be made aware that a report is forthcoming. Moving forward, re-training will occur form the IM point person and if patterns develop with staff or there is disregard to policies and procedures by staff, progressive discipline will occur immediately. |
03/26/2018
| Implemented |
| 6400.43(b)(1) | The administration and management of individual funds policy states that wallets will be counted daily. According to incident report filed, Individual #1's wallet was last counted on 8/26/17 and was not attempted to be counted again until 8/28/17 when it was discovered missing. Individual #1's wallet was never found and he/she was refunded the missing $25 dollars on 8/31/17. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | The DSP that did not count wallets on 8-27-17 was retrained by the IM Point Person on the policy titled Administration and Management of Funds as well as IM procedures. An Associate Director has now been hired to oversee the home and it is their responsibility to count wallets during home visits, and to ensure staff are counting and documenting daily as per policy and procedure. Additionally, see attachment # 18 of home visit report which was revised 3-28-18 to include the additional responsibility of the counting of wallets by any management person making visits to the home (change of practice). The Associate Directors will be starting the disciplinary procedure for DSP's that do not follow policies/procedures. |
03/28/2018
| Implemented |
| 6400.44(b)(18) | Individual #1 was diagnosed in 2014 with hydrocephalis. On 8/5/17 a cat scan was completed which confirmed Individual #1 still had hydrocephalis. The results of the cat scan were not printed and put in his/her book until 2/13/18. No staff working with Individual #1 have been trained on the diagnosis of hydrocephalis and side effects. There is no documentation that staff were trained or aware of the note from his/her doctor regarding hygiene concerns. There is no documentation that staff were trained in Individual #1's behavior support plan, blood sugar protocol, how to test blood sugar levels, individual support plan, medical history and side effects of medications. During an interview with staff it was stated by the staff that he/she did not receive formal training on Individual #1's health and safety needs. | The program specialist shall be responsible for the following: Coordinating the training of direct service workers in the content of health and safety needs relevant to each individual. | The Program Specialist has requested through the local HCQU on 2-27-18 for a training on hydrocephalus to be set up and completed for agency staff. See attachment 14. The training attendance sheet will be forwarded to licensing when the training occurs as it sometime takes 2 - 3 months to get the training set up. The program specialist will ensure in the future that training specific to the health, safety, and welfare of individuals is coordinated and completed in a timely manner. |
02/27/2018
| Implemented |
| 6400.61(a) | Individual #1's primary care physician wrote in a note to the residential provider about concerns regarding Individual #1's hygiene. The residential provider does not track Individual #1's showering habits. The agency reported to licensing on 2/21/18 that Individual #1 does not bathe in his/her shower due to being afraid of the shower. Staff reported that Individual #1 indicated he/she does not want to shower in the other bathroom of the home because other female ladies in the home utilize that shower. Individual #1 has ambulation concerns and has fallen multiple time over the past year. Individual #1's current bathroom has a bathtub as opposed to a walk in shower. Individual #1 reported on 2/22/18 that he/she is scared of the drop off the back porch. There are no railings currently in place to prevent someone from tripping off the back porch. The drop is approximately one foot high. Individual #1 has ambulation concerns and Individual #2 utilizes a walker to assist with ambulating. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | see attachment 9 - Refusal for shower plan and shower chart dated 3-7-18. Furthermore Shadowfax is renovating the bathroom of individual # 1 with a tentative date to start the week of April 9, 2018. Shadowfax will provide pictures of the completed bath tub once done. On 3-27-18 a handrail was installed off the back patio - see attached pictures of before and after. Moving forward, the Associate Director will be responsible to ensure that the home has all necessary accommodations to meet the individual needs of the people living there and to ensure reasonable accessibility and document on house visit forms and notify maintenance if necessary. |
04/30/2018
| Implemented |
| 6400.64(a) | The curtains in Individual #1's bedroom had approximately one inch of dust on them. | Clean and sanitary conditions shall be maintained in the home. | The Associate Director of the home instructed staff to clean the curtains. See attached house visit report showing that the curtain dust has been addressed - attachment #16. The Associate Director position for this home had been vacant the prior year and has now been filled. The Associate Director will be responsible to ensure the cleanliness of the home on future visits. Additionally, Shadowfax will change practices in the future if a home does not have an Associate Director. The Senior AD, another AD, or the Director will be assigned and be responsible to make weekly visits to ensure clean and sanitary conditions are maintained in the home. |
03/28/2018
| Implemented |
| 6400.72(b) | Repeat 5/9/17: Individual #1's screen sliding door would only slide approximately one foot before getting stuck on multiple leaves and debris in the track of the door. | Screens, windows and doors shall be in good repair. | Maintenance cleaned the sliding door track of debris on 2/23/18 and again on 3-27-18. See; house visit report dated 3-28-18 (attachment 16) that shows that the door opens and is free from debris. Also review picture of railing installed as his bedroom door is wide open as proof it opens more than 1 foot. The Associate Director will be responsible moving forward to ensure all means of egress are clear and in good repair. Additionally, Shadowfax will change practices in the future if a home does not have an Associate Director. The Senior AD, another AD, or the Director will be assigned and be responsible to make weekly visits to ensure screens, window, and doors are in good repair. |
03/28/2018
| Implemented |
| 6400.141(c)(14) | Individual #1's physical dated 1/17/18 stated under information pertinent to diagnosis and treatment in case of emergency to take Individual #1 to York Hospital. This section did not indicate his/her refusals, diagnosis of hydrocephalus, dementia and confusion. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | On 3-7-18, the program specialist mailed a memo to all team members and PCP to add these items under diagnoses and medical information pertinent to diagnoses and treatment in case of an emergency. See attachment 4. Additionally, Shadowfax is hiring more program specialists and has hired an administrative assistant to cross check all documentation to ensure consistency and accuracy. The program specialists were trained on 2-23-18 regarding adding information or more information for better emergency notification to the physical examination. |
03/07/2018
| Implemented |
| 6400.142(a) | Repeat 11/30/16: Individual #1 was recommended to see the dentist every three months or more frequently as needed. Individual #1 saw his/her dentist on 6/13/17 and not again until 10/27/17. There is no documentation that Individual #1 was seen by the dentist after 10/27/17. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Individual 1 is to be seen every 3 months by his periodontist and the dentist as per the recommendation of the periodontist. He was seen in June 2017, their office canceled the August 2017 appointment - attachment 11 - and couldn't be seen until October 2017. Staff who received the call did not document the cancelation of the appointment. He was seen 5 months after October 2017. Shadowfax is hiring 2 additional Program Specialists to ensure the oversight of appointments. Additionally an Associate Director is now assigned to this home to double check that appointments are scheduled and are met. All Associate Directors met on 3-13-18 to check the dates of all upcoming appointments to ensure they have been scheduled and meet regulatory requirements. Because this individual is not due again for a dental appointment until June 2018, see attachment # 12 of an individual who has had a dental appointment on time since inspection (3/23/18). The Associate Director will be monitoring appointments in this home to ensure individual 1 (as well as his housemates) seen on time in the future. |
03/23/2018
| Implemented |
| 6400.142(d) | Individual #1's 2017 and 2018 physical exam forms indicate that he/she requires dental care every three months. A cleaning occurred on 8/24/16 and not again. Dental forms for dental appointments on 6/13/17 and 10/27/17 did not indicate that a cleaning was completed at these appointments. | The dental examination shall include teeth cleaning or checking gums and dentures. | See attachment # 11 of periodontist dates and cleanings done. Documentation training was held for all Associate Directors & Program Specialist on 3-26-18 - attachment 6 - to ensure that Shadowfax's documentation from the appointments show what exactly was completed during the appt. The Associate Director will be responsible to ensure this form is completed correctly moving forward. The Program Specialist will be a double check of the documentation. |
03/28/2018
| Implemented |
| 6400.142(f) | Individual #1's dental hygiene plan did not include the use of a water pick and night guard as recommended by his/her dentist. Individual #1's hygiene plan did not indicate his/her refusal to follow the dental plan. Individual #1's plan only indicated that he/she is independent and needed occasional verbal reminders to brush and use toothpaste. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The night guard was documented on the dental hygiene plan but the water pik was not listed. See attached updated dental hygiene plan updated by the Program Specialist dated 3-28-18 as well as the chart (attachment # 13). Staff will document any refusals daily on the chart. Going forward, the Program Specialist will review the periodontist recommendations and ensure the dental hygiene plan is updated. The Director will monitor that the Program Specialist is updating all documentation promptly. |
03/28/2018
| Implemented |
| 6400.143(a) | On 7/6/17 Individual #1 was having symptoms of slurred speech and the side of his/her face was drooping. Individual #1 refused to go to the hospital. On 7/12/17 Individual #1 followed up with the primary care physician (PCP) and it was recommended that he/she have a CT scan completed. Individual #1 refused to have the scan done. Individual #1 refuses to shower on a daily basis even though his/her physical form indicates to do so and the PCP has expressed concerns regarding hygiene. There is no documentation of Individual #1's medical and health refusals or attempts to retrain him/her. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A refusal for shower plan was developed March 7, 2018 and staff are completing a refusal chart (see attachment 9). Individual # 1 does not usually refuse routine medical appointments but refuses emergency medical care. The PS discussed verbally with the individual on 2-26-18 the necessity of cooperating for emergency appointments and follow up care and testing. Individual # 1 gets angry when pushed in situations. When he is truly sick or ill, he does not usually refuse care. The PS developed a plan on 3-27-18 to discuss with individual # 1 once a month to be reviewed by a staff that he trusts and has a long standing rapport with in order to educate him on the necessity of being checked even when he does not feel it is an emergency. See attachment 10. Moving forward,. the Associate Director will continue to educate the individual as necessary to ensure he gets proper care. |
03/27/2018
| Implemented |
| 6400.162(a) | The medication label for Individual #1's deep sea spray is not legible. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | A new bottle of sea spray was in the closet with a legible label. The bottle with the label not legible was discarded on 2-23-18 as it was almost empty. The Director re-trained all Associate Directors on checking medication labels. To prevent further occurrences, the Associate Director will check medication labels on a weekly basis to ensure they meet the regulatory guidelines. The Director will make spot checks in all the homes on visits as a double check. |
02/23/2018
| Implemented |
| 6400.163(c) | Individual #1's medication review completed on 6/6/17 did not include the need to continue Seroquel 200 mg at 8 am and 400 mg at 8 pm. The same medication review did not include the reason for prescribing Seroquel 25 mg at 8 am. Individual #1's March 2017 medication administration record (MAR) indicated Trazadone 100 mg (give 2 tablets) was prescribed and given for depression/sleep however this medication was not reviewed on Individual #1's medication reviews until 8/29/17. This medication was prescribed for the entire year. Individual #1's medication review completed on 12/4/16 indicated to administer Seroquel 200 mg at 8 pm however the December 2016 medication administration log indicates that Seroquel 200 mg was administered at morning and at night. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | All staff will verify the accuracy of the paperwork before leaving the dr. office to be ensure everything is completed thoroughly and accurately. The PS will double check the forms. At his DPI review on 5-1-18, all diagnosis will be clarified and the form will be accurately completed. After the completion of the appointment, a team meeting will be held to ensure staff are trained on the diagnoses and to ensure the correct times, dosages, and diagnoses are listed correctly on all forms. Moving forward the Associate Director will ensure accurate documentation as per the importance of proper documentation training held on 3-26-18 - see attachment 6 |
05/01/2018
| Implemented |
| 6400.164(a) | Individual #1's July 2017 medication appointment form indicated that between 7/12/17 and 7/19/17 he/she took evening medications, felt sick, threw them up and then retook the medications. The July 2017 medication administration record (MAR) did not indicate that any medications were re-administered. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | A medication error training is being held 4-10-18 to re-train staff on proper administration and documentation. Shadowfax has medication questionnaire's that the physician complete on what to do if the person vomits their medications. Unfortunately, the staff did not properly document this. 2 additional staff and an Associate Director have been hired for this home to provide consistency and to ensure refills are called in promptly. The training signature sheet will be forwarded to licensing upon completion. |
04/10/2018
| Implemented |
| 6400.164(b) | Repeat 12/14/16: Individual #1's Vitamin D was not logged immediately after administration on 2/10/18. Staff #2 indicated that the medication was administered on this date but not initialed for. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | An Associate Director has been hired and is now making (at least) weekly visits to the home to check charts and ensure medication is logged immediately. A medication error training is being held April 10, 2018 to re-educate staff on proper medication administration and documentation. Moving forward, the Associate Director is responsible to ensure all medication is administered and documented appropriately. Discipline up to and including termination will occur by the Associate Director if staff do not document the MAR immediately after administration occurs |
04/10/2018
| Implemented |
| 6400.165 | Individual #1's August 2017 medication administration record (MAR) indicated that on 8/18/17 his/her 6 am does of levothyroxine was not given until 7:48 am. Individual #1's August 2017 MAR indicates that on 8/31/17 his/her 8 pm dose of Lipitor 20 mg was omitted due to this prescribed medication not being available at the house. | Documentation of medication errors and follow-up action taken shall be kept.
| A medication error training is being held 4-10-18 to re-train staff on proper administration and documentation. 2 additional staff and an Associate Director have been hired for this home to provide consistency and to ensure refills are called in promptly. The training signature sheet will be forwarded to licensing upon completion. Additionally, the Associate Director will monitor staff and provide feedback and discipline as necessary in regard to medication administration. |
04/10/2018
| Not Implemented |
| 6400.167(b) | Individual #1's medical appointment form indicated that between 7/12/17 and 7/19/17 Staff #3 reported that there was an 8:30 pm call to Individual #1's doctor, Dr. Joseph. Staff #3 reported on the form that Individual #1 took his/her medications and felt sick, then threw up and re-took the medications. There was no prescription in the record indicating the medications could be administered again. On 2/10/18 Individual #1's February MAR did not have a staff signature for his/her finasteride 5 mg medication. It stated that the medication was not given due to the medication not being re-ordered. Staff indicated on the February 2018 MAR that on 2/3/18 Individual #1's quentiapine fumarate medication was not administered until 7:48 am. This medication was unable to be administered at the correct time of 6 am due to the medication not being refilled in time. Individual #1's psychiatrist discontinued his/her medication of Amantadine on 2/13/18 however the home continued to administer this medication until 2/22/18. The home was made aware by licensing staff on 2/22/18 that the medication was discontinued by the doctor. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | A medication error training is being held 4-10-18 to re-train staff on proper administration and documentation. Shadowfax has medication questionnaire's that the physician completes on what to do if the person vomits their medications. Unfortunately, the staff did not properly document this. The medication error training will also cover re-ordering medication. 2 additional staff and an Associate Director have been hired for this home to provide consistency and to ensure refills are called in promptly. Per medication administration training, medications are not to be started or discontinued until written documentation is acquired which is why staff continued to administer the medication. There was no oversight to ensure the follow up documentation was received. The home now has an Associate Director who is responsible to ensure this. Shadowfax is hiring additional program specialists so that the work load is minimized and the Program Specialists can spend more time in the homes providing oversight. The medication error training signature sheet will be forwarded to licensing upon completion of the training. |
04/10/2018
| Implemented |
| 6400.168(d) | Staff #3 had medication administration training on 11/9/16 and not again until 11/15/17. The last observation was not completed until 11/15/17. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | Staff #3 acquired the medication practicum with the trainer. The trainer is changing the due dates to be a quarter early and do the practicum every 6 months as required which allows a 3 month leeway in case someone is ill, on vacation, or has to reschedule for another reason (allowing make up time to be within the regulatory guideline). This change in practice will be implemented May 1, 2018 to prevent future occurrences of late med administration training. |
05/01/2018
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment completed on 8/17/17 indicates that he/she has up to four hours a day of unsupervised time at home, then indicates that he/she is unable to be in any room without direct supervision. It is unclear what Individual #1's supervision needs are. | The assessment must include the following information: The individual's need for supervision.
| The PS sent a memo to all team members on 3-7-18 to clarify that there had been a typo to correct that he is ABLE to be in any room without direct supervision (see attachment # 4). In order to prevent future occurrences, Shadowfax has hired a residential administrative person to review ISP's and assessments against all other documentation in the record to ensure all information matches. Also, Shadowfax is hiring additional program specialists to lighten the work load so more time is spent on each individuals chart to ensure accuracy and matching documentation. |
03/07/2018
| Implemented |
| 6400.181(e)(10) | Individual #1's lifetime medical history last updated on 2/10/18 does not include his/her recent medical history of stroke like symptoms which occurred on 7/6/17, refusal to complete a CT scan as recommended by his/her physician and a hospitalization due to a fall from bed on 8/18/17. | The assessment must include the following information: A lifetime medical history. | The lifetime medical history was updated by the PS on 3-7-18 and again on 3-28-18 and submitted to the physician. Individual # 1 had an appointment on 3-30-18 and staff provided the medical history to the physician to be signed as proof that the information was compiled and added to the medical history. (See attachment 8). The Director re-trained the PS's on the importance of including refusals in the lifetime medical history with regard to important medical issues - see attachment # 3. The Program Specialist also discussed with the individual the importance of complying and cooperating with medical appointments to ensure his best overall health. |
03/28/2018
| Implemented |
| 6400.181(e)(13)(i) | Individual #1's assessment completed on 8/17/17 does not include his/her progress over the last 365 calendar days in the area of health. Individual #1 had health concerns over the past year that were not included in the health section of the assessment. It was documented in the ISP that over the past year Individual #1 experienced an increase in memory loss and confusion. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| See attachment 4B. The Program Specialist notified team members on 3-7-18 of progress/regression in the areas of health in the assessment. In order to prevent future occurrences, Shadowfax has hired a residential administrative person to review ISP's and assessments against all other documentation in the record to ensure all information matches (since the ISP noted an increase in memory loss and confusion but the assessment did not match). Furthermore Shadowfax is hiring additional Program Specialists so the work load is lessened on the current PS's so that more time can be devoted to monitoring the ISP and assessment information. The Program Specialists were re-trained on 2-23-18 to not only include all areas of progress but areas in which regression has also occurred. |
03/07/2018
| Implemented |
| 6400.181(e)(13)(ii) | Individual #1's assessment completed on 8/17/17 does not indicate his/her progress over the last 365 calendar days in the area of motor skills. Individual #1 has had an increase in falls and an unsteady gait over the past year as indicated in his/her ISP. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | See attachment 4. The Program Specialist notified all team members of the increase in falls. Shadowfax is hiring additional Program Specialists so the work load is lessened on the current Program Specialists so that more time can be spent monitoring ISP and assessment information. One of the additional Program Specialists is slated to start 4/23/18. Furthermore, the Director will monitor records to ensure information is accurate and consistent. The Program Specialists were re-trained on 2-23-18 to not only include all areas of progress but areas in which regression has also occurred. |
03/07/2018
| Implemented |
| 6400.183(4) | Individual #1's individual support plan (ISP) did not include his/her supervision levels while in the community. Individual #1's ISP did not include the length of time he/she is allowed to be unsupervised in the store or bank. The ISP for Individual #1 indicates he/she can run into a store or bank to pick up something quick. Individual #1's ISP indicates he/she can have up to four hours of unsupervised time at home but does not indicate a plan to increase unsupervised time. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Individual # 1's plan for unsupervised time states that he does not want to work on increasing his unsupervised time (plan dated 8-17-17). The Program Specialist has emailed the SC on 3-28-18 to include this statement specifically in the ISP (attachment 7). The ISP does state that individual # 1 can go into the bank or store to pick something up quick as long as he is comfortable with the situation and staff are close by. it does not specify a time frame as one does not know how long you may have to wait in line. However, the PS has emailed the SC on 3-28-18 to specify up to 15 minutes each time in this situation. Going forward, the PS will ensure that specific time frames are in all documents and all documentation matches. The Director will monitor the PS plans to ensure it meets regulatory guidelines. Additionally, an administrative assistant was hired as an additional check for content discrepancy. |
03/28/2018
| Implemented |
| 6400.183(5) | Repeat 11/30/16: Individual #1's social, emotional, environmental needs (SEEN) plan in his/her ISP does not include the diagnosis of anxiety, impulse control disorder, mood disorder and depression as indicated on the medication review forms. Individual #1's SEEN in the ISP also does not include symptoms of those diagnosis. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | See attachment 5G. The psychiatry office on 3-28-18 stated for billing purposes, they use the mood disorder for Luvox, for Seroquel they use impulse and Mood disorder, for Lithium they use mood disorder, and for Trazadone they use insomnia. Bipolar is a mood disorder and mood disorders include anxiety and depression which were all listed on the DPI forms. Intermittent Explosive Disorder is a type of Impulse control. At his next face to face diagnosed psychiatric review on 5-1-18, Shadowfax staff will have the psychiatrist document the exact reasons for prescribing all psychotropic medications and all forms will be clarified/corrected to match. The SEEN plan will be clarified after individual # 1's psych appointment on 5-1-18. Moving forward, the Program Specialist as well as the Associate Director will ensure all documentation matches. Additionally, the staff at the appointment will verify that what the doctor writes at each appointment matches what the doctor has previously written in the records. |
05/02/2018
| Implemented |
| 6400.212(b) | Individual #1's physical dated 1/17/18 contained hand written information about his/her diet, urinalysis, hemacult and medications with staff #1's initials but no date of when this information was added. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| On 2-23-18, the Director of Residential trained all Program Specialists on the importance of signing and dating all entries (attachment # 3). Each Program Specialist is now aware of the importance of signing and dating all entries. Furthermore, a documentation training was completed on 3/26/18 with all Residential Management (attachment # 6). Shadowfax is hiring additional Program Specialists so the Program Specialists have less work load in order to spend more time ensuring accurate and thorough documentation. Going forward the Director will provide ongoing monitoring by checking records to ensure all entries are signed and dated. |
02/23/2018
| Implemented |
| 6400.213(11) | Repeat 11/30/16 and 12/14/16: Individual #1's identification sheet listed his/her diet as low carbs, sugar substitute and caffeine free. Individual #1's physical dated 1/17/18 indicated a low carb, sugar substitute, caffeine free, no salty snacks, no added salt, maintain 2 gm sodium restriction diet. Individual #1's ISP does not include low salt snacks and no added salt as part of his/her diet. Individual #1's ISP does not indicate his/her allergy to Levaquin. It only stated he/she had seasonal allergies and an allergy to niacin. Individual #1's medication log did not did not indicate his/her allergy to Levaquin. On Individual #1's 12/6/16 medication reviewed the following medications and reason for prescribing: quetiapine 25 mg at 8 am for impulse control disorder, quetiapine 200 mg at 8 pm for impulse control, luvox 100 mg at 8 am and 50 mg at 8 pm for impulse control and lithium carb 300 mg for impulse control. Individual #1's medication administration record for December 2016 states that Luvox is prescribed for IED, Lithium Carb is prescribed for bipolar disorder and Seroquel is prescribed for a mood disorder. Individual #1's medication review completed on 3/7/17 indicates that Luvox 100 mg at 8 am is and 150 mg at 8 pm were prescribed for anxiety, Lithium Carb. 610 mg at 8 am, 300 mg at 1 pm and 610 mg at 8 pm were prescribed for mood disorder. The 3/7/17 medication review form also indicates that Seroquel 25 mg at 8 am, 200 gm at 8 am and 400 mg at 8 pm are taken for a mood disorder. Individual #1's medication administration record for March of 2017 stated that Luvox was prescribed for IED, Lithium Carb for Bipolar disorder and Seroquel for mood disorder. Individual #1's ISP lists Luvox, Seroquel, Fluvoxmine and maleate are taken for IED and Lithium carb for bipolar. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | The Program Specialist clarified discrepancies with the Supports Coordinator (Plan Lead) on 3-7-18- see attachment # 4 regarding allergy to Levaquin. All forms now include the Levaquin allergy. See attachments 5A-5Gclarifying the diet and all corresponding paperwork relating to matching of subsequent dietary instructions. The Program Specialist contacted the psychiatrist office regarding the reasons for prescribing the psychotropic medications. The psychiatry office on 3-28-18 stated for billing purposes, they use the mood disorder for Luvox, for Seroquel they use impulse and Mood disorder, for Lithium they use mood disorder, and for Trazadone they use insomnia. Bipolar is a mood disorder and mood disorders include anxiety and depression which were all listed on the DPI forms. Intermittent Explosive Disorder is a type of Impulse control. At his next face to face diagnosed psychiatric review on 5-1-18, Shadowfax staff will have the psychiatrist document the exact reasons for prescribing all psychotropic medications and all forms will be clarified/corrected to match by the Program Specialist after this appointment. Shadowfax is in the process of hiring additional Program Specialists to lighten the work load of current Program Specialist so more time can be spent ensuring all paperwork matches. Furthermore, an administrative assistant was hired to also check for content discrepancy. |
05/01/2018
| Implemented |
| 6400.215(a) | All of Individual #1's records are not being kept at his/her home. Individual #1 had a Wellspan medical appointment on 1/17/18 which was not in his/her record. At this medical appointment it was indicated that Individual #1 is to discontinue sodium chloride, omega-3, Chloraseptic and bacitracin. This form also indicated a fall risk screening was done on 11/28/17 for Individual #1 however there is not record of this in his/her file. | Information in the individual's record shall be kept for at least 4 years or until any audit or litigation is resolved. | Information from the 1/17/18 appointment was documented on the individuals' Monthly Medical Review in both the office and home books, and was attached to the physical examination form as well in both books. The Wellspan paperwork referenced is from the patient portal which has not been standard practice of Shadowfax to print out those reports as they often contain inaccurate or wrong information. For example, it listed Choraseptic and Bacitracin, both medications that had been used months prior and were discontinued. These were Over the Counter medications used on a PRN basis. The Sodium Chloride and Omega-3 were discontinued the day of the medical appointment as directed. Unbeknownst to Shadowfax staff and individual # 1's PCP, the psychiatrist completed a fall risk assessment. This was obtained on 2-22-18 and shared with licensing personnel at the time of the on site review. The fall risk assessment contained no recommendations. However, the Program Specialist formulated a fall plan and chart on 3-27-18. The PS's have now been trained on printing out the portal pages, reviewing them to ensure follow up, and emailing physicians when information is inaccurate or inconsistencies are found. This training occurred on 2-23-18. The Program Specialists and the residential department keep all current pertinent information in the office and home books and records are kept in the administrative office for 5 years or until litigation is resolved. Falling Plan and chart are attachment # 1 and 2 and training and signature sheet of Program Specialistsis attachment # 3. All staff that work with this individual will be trained on the fall plan by 4-10-18. |
03/27/2018
| Implemented |